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DQA Quarterly Information Update

April 2009

PDF Version of this month's Quarterly Update (PDF, 110 KB)




  • DQA Focus 2009 Conference ....... October 21 - 22

Bureau of Assisted Living Restructuring

Effective April 1, 2009, the Bureau of Assisted Living ceased operations in the Northern Regional Office located in Rhinelander. Facilities previously assigned to the Northern Regional Office have been reassigned to the Western Regional Office in Eau Claire, the Northeastern Regional Office in De Pere, and the Southern Regional Office in Madison. DQA memo 09-011 contains links to the new regional maps, surveyor regional assignments and updated telephone numbers.

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DQA Focus 2009 Conference

The Wisconsin Department of Health Services, Division of Quality Assurance, is pleased to announce the 9th annual conference for health care providers and DQA staff on October 22, 2009, at the Kalahari Convention Center in Wisconsin Dells. The Focus 2009 conference is being developed in collaboration with health care providers and associations and is designed to bring a best-in-the-industry lineup of presenters to challenge and improve your day-to-day work.

Focus 2009, "Furthering Our Commitment to Ultimate Service," will provide an exceptional lineup of presentations. The conference will feature two keynote speakers. Dr. Gregory Poland will kick off the conference with a presentation entitled "Influenza Immunization of Health Care Workers." Dr. Poland is a national and international expert in the field of vaccinology and clinical research and is the director of Mayo Clinic's Vaccine Research Group. In the afternoon, the keynote speaker will be Clint Maun. Clint is a nationally recognized leader in healthcare consulting, speaking, and research.

On October 21, 2009, prior to Focus 2009, DQA will offer two special sessions: "The Art and Science of Pressure Ulcer Prevention and Treatment" and "The ServSafe Training." The "Art and Science of Pressure Ulcer Prevention and Treatment" will feature pressure ulcer expert Joyce Black, Ph.D., former president of the National Pressure Ulcer Advisory Panel.

"The ServSafe Training" will be taught by Certified ServSafe Instructor, Rich Daehn. The ServSafe Training will provide participants with the knowledge, skills, and abilities needed to set high food safety standards. Upon completion of the ServSafe course, participants will be given the opportunity to take an approved exam to become a Certified Dietary Manager.

We are excited about this year's conference. Please save the dates!

More information will be included on our conference website as plans are finalized. Please visit:

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DHS 35 New Outpatient Mental Health Clinic Rule

The new DHS 35 will likely be published sometime in May 2009 with an anticipated effective date of June 1, 2009. The Division of Mental Health and Substance Abuse Services and the Division of Quality Assurance issued a joint memo announcing training events for the new rule. Refer to joint DQA/DMHSAS memo 09-008 for additional information at:

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REMINDER!! Basic Home Health Online Course

The Basic Home Health Online Course is an educational course that provides individuals that take the training with the opportunity to learn the basic federal home health regulations. This interactive course is intended to build a foundation of understanding about the home health agency federal regulations. The federal home health agency Conditions of Participation (CoPs) and Appendix B of the State Operations Manual (SOM) are the basis for this course. Appendix B includes the regulations, interpretative guidelines, and questions to consider when determining if home health agencies are following federal regulations.

Many home health agency staff have already taken the course and provided very positive feedback.

The cost to take the course is $25.00 per person. The course is available 24/7 via the Internet. Additional information is included in the course description located on the registration website.

Register online at:

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Medication Black Box Warnings: What Nursing Homes Need to Know

Each day more information becomes available regarding the use of antipsychotic medications for elderly individuals with dementia. Since 2005, a black box warning has existed for the newer generation of antipsychotics. Recently the older antipsychotic medications have also been given the same black box warning. For antipsychotics, the black box warning is a high level precaution warning prescribers that the use of antipsychotic medications in elderly individuals with dementia, or related illnesses, can cause death.

The Division of Quality Assurance (DQA) has previously addressed the use of antipsychotic medications that are prescribed to elderly residents with dementia. Please review the links to previously issued pharmacy newsletters on this subject. Federally certified nursing homes are also encouraged to review the Medicare State Operations Manual and the guidance specific to the use of antipsychotic medications.

Please remember that when antipsychotic medications are used for nursing home resident behaviors that are not associated with a mental illness there are multiple conditions that must be met to avoid the risk of a deficient practice citation. Due to the black box warning and the nature of the medication, facilities should be developing plans of care specific to the antipsychotic medication that include monitoring for the medication's effectiveness and side effects. 

Existing regulations have not changed with federal Food and Drug Administration advisories issued in previous years regarding black box warnings. Facilities must discuss with residents, families, legal representatives, the consultant pharmacist, medical director, and physicians the use of these medications, including a thorough discussion of the risks, benefits, and potential side effects before starting or making any changes with antipsychotic therapy. 

This is especially important when antipsychotic medications are used for behaviors related to Alzheimer's Disease, dementia or other organic brain disorders. While written informed consent is not mandatory for the use of antipsychotic medication to treat dementia-related behaviors, it has become a common practice for nursing homes to document this type of consent. We encourage nursing homes to continue this process. 

The Department has made available a form used in facilities operated by the Department, but accessible to the public. Please access the Department's website at for an updated version of the form. If, however, a nursing home chooses to implement its own form, care must be given to ensuring that the document contains sufficient information needed for a proper informed consent to be granted. Please continue to check the above website for any updates made to this form.

Facilities need to have information which supports that the facility has considered all the standards related to antipsychotic medication use in behaviors that are the result of Alzheimer's Disease, dementia, or other organic brain disorders. When antipsychotic medications are being used for behavior treatment, a specific monitoring program that looks at effectiveness and side effects, must be in place. 

Monitoring includes appropriately training direct care staff on recognizing the signs and symptoms that may appear due to a resident taking these medications. This is important in determining the drug's effectiveness, or lack thereof. Continuous communication between nursing staff and the facility's medical director and pharmacy consultant is, therefore, critical to ongoing monitoring within the facility.

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Nurse Aide Registry Transfers

An individual may apply to transfer from one state's nurse aide registry to another state's nurse aide registry. However, the person should always contact the state registry that they wish to transfer to in order to learn what that state's eligibility requirements are for placement on that registry. Although all states must comply with the federal requirements, each state established its own rules regarding the management of their individual registry.

An individual wishing to transfer their nurse aide status to the Wisconsin Nurse Aide Registry must satisfy all of the following:

  • Satisfactory completion of a nurse aide training program of at least 120 hours, of which 32 of those hours were in a clinical setting.
  • After completion of the training program, satisfactory completion of a comprehensive nurse aide competency examination, which included both written and skills.
  • Eligibility to work in federally-certified nursing homes and Intermediate Care Facilities for persons with Mental Retardation (ICF/MRs).

The names of individuals who meet these requirements will be placed on the Wisconsin Nurse Aide Registry.

Individuals who do not meet the above requirements may become eligible for placement on the Wisconsin Nurse Aide Registry by satisfying one of the following:

  • An individual, who is listed on another state's registry but has not completed a nurse aide training program of 120 hours, must successfully complete both a 120 hour nurse aide training program and a comprehensive competency exam (including both written and skills components).
  • An individual, who is listed on another state's registry and who has completed a nurse aide training program of at least 120 hours but did not take a comprehensive competency examination, will be required to successfully complete the Wisconsin competency examination.
  • An individual, who is listed on another state's registry, has completed a nurse aide training program of at least 120 hours and a comprehensive competency examination but their eligibility to work in a federally-certified healthcare setting has expired, will be required to successfully complete the Wisconsin competency examination.
  • An individual, who is not listed on another state's registry but has completed an approved nurse aide training program of at least 120 hours in that state within the last year but has not taken a comprehensive competency examination, will be required to successfully complete the Wisconsin competency examination.

A nurse aide wishing to transfer to the Wisconsin Nurse Aide Registry must complete and submit a Nurse Aide Registry Out-of-State Application.

  • Individuals transferring from California, Colorado, Illinois, Missouri, North and South Carolina should send the application to:

Office of Caregiver Quality
P.O. Box 2969
Madison, WI 53701

  • All other nurse aides should mail the out-of-state application to the state registry that they are currently listed on.

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Wireless Handheld Device Usage

As the popularity of wireless handheld devices and social networking websites increases, so does the potential for misuse or abuse by electronic means. The Office of Caregiver Quality is currently drafting a memo to provide facilities with some guidance regarding the use of wireless devices such as cell phones, cameras, personal digital assistants (PDAs) and laptops.

OCQ has seen an increase in the number of caregiver misconduct complaints regarding the misuse of these devices and encourages all entities to be proactive in protecting their clients by adopting written policies that define appropriate and inappropriate use. If your facility has adopted policies or procedures addressing these issues and would like to share examples, please contact OCQ at the number or e-mail address below.

Questions?  Contact the DQA Office of Caregiver Quality at:
(608) 261-8319 Telephone
(608) 264-6340 FAX

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MDS 3.0 Delayed

CMS has revised the implementation date for MDS 3.0 to October 1, 2010. CMS has stated that in October of 2009, a finalized version of the revised data specifications, RAI Manual version 3.0, and MDS 3.0 forms will be published. We are hopeful that this extended roll out will give all stakeholders time for a comprehensive and smooth transition to a new and improved assessment tool.

Nursing homes are encouraged to participate in CMS Skilled Nursing Facilities/Long Term Care Open Door Forums to stay updated on the MDS and related issues of significance for nursing facilities. Facilities may sign up to receive e-mail notification of Open Door Forums at the following website:

Revisions to the RAI Manual 2.0

The December 2008 revisions to the RAI Manual 2.0 are available on the CMS MDS 2.0 website. Updates can be viewed and downloaded at:

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Home Health OASIS-C: History and Update

Development of the next major revision of OASIS, termed "OASIS-C," began in 2005. Field-testing was completed in 2008. The Centers for Medicare and Medicaid Services (CMS) has advanced through several drafts of OASIS-C and remains on task for a final version to become effective January 1, 2010. CMS held a public comment period, which ended January 13, 2009, and has completed its review and response to the public comments, resulting in 'version 12.2' of OASIS-C.

An earlier draft of OASIS-C was originally posted to CMS's 'Paperwork Reduction Act of 1995' website. Version 12.2 is now posted to CMS's 'Home Health Quality Initiative' website, located at: Once on this website, select 'OASIS-C' from the left-hand column. Then, scroll to the bottom of the web-page to view OASIS-C version 12.2, CMS's response to public commentary, and the March 9, 2009 Federal Register notice of CMS's request for OMB approval to modify the OASIS data set.

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Changes in DQA Staff

Bureau of Assisted Living - SRO

Ms. Emily Schmitt joined the Southern Regional office as a License/Permit Program Associate in the Bureau of Assisted Living on 1/20/2009. Emily is a very recent graduate of the University Wisconsin - Madison in Sociology and Social Welfare. While at the University, she was employed by the UW Office of Student Financial Services as an Information Specialist and Imaging Specialist. Emily volunteered with HospiceCare and The Salvation Army and served on a number of committees while attending the university.

Bureau of Assisted Living - SERO

Renee Polley joined the Southeastern Regional office as a License/Permit Program Associate in the Bureau of Assisted Living on 3/2/2009. Renee is a graduate of Mount Mary College and has completed graduate level courses in management and Information Technology. Renee transferred from the University of Wisconsin - Whitewater where she provided administrative support. Renee brings a wide variety of experiences and talents to her position in the Bureau of Assisted Living.

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DQA Numbered Memos (January, February, March)

Access these memos via
or via individual providers' publications pages at

DQA Memos

Memo No.



Providers Affected

08-030 08-030 - Implementation of Wisconsin Administrative Code DHS - OBSOLETE 9/13 DQA Memo 08-026 announced legislative approval of revisions to DHS 129. This memo provides direction and guidance regarding the actual implementation of the changes that affect the training of nurse aides as of 12/01/08. Nurse Aide Training
09-001 09-001 - Advanced Practice Nurse Prescribers in Assisted Living - OBSOLETE 9/13 Memo addresses some general issues related to advanced practice nurses (APNs) and advanced practice nurse prescribers (APNPs) practicing in assisted living facilities. Additionally, this memo creates a general variance to specific rules that may have limited APNPs from fully practicing in certain assisted living facilities. Community-based
Residential Facilities
OBSOLETED by 09- 007
Adult Family Homes
09-002 Notice to update Facility Administrator Information - OBSOLETED by 09-007    
09-003 "New" DQA Website - Construction/Remodeling for Health Care Facilities
"New" Plan Approval Application Form On-line Access to the Status of Plan Review Application
All plan review applications and other forms have been modified and improved and their use is required for all projects received in DQA as of 02/01/09.
DQA has also redesigned its construction / remodeling website which includes access to an on-line report that provides applicants an opportunity to check the status of their application as it moves through the internal review processes.
Nursing Homes
Facilities for the Developmentally Disabled
Community Based Residential Facilities
09-004 Electronic Delivery of Clinical Lab Improvement Amendments (CLIA) Updates The purpose of this memo is to inform you of a new process for receiving updates pertinent to CLIA certified laboratories. In meeting the DQA goal of making information accessible to providers, CLIA laboratory updates will be added to DQA's listserv. CLIA Certified
09-005 Revised Wisconsin Administrative Code, Chapter DHS 83, Effective April 1, 2009 On 04/01/09, DHS will implement its revised Wis. Admin. Code, ch. DHS 83, regulating community-based residential facilities. This memo provides important information about implementation and training and a guideline of changes. Community-based
Residential Facilities
09-006 Wisconsin's Feeding Assistant Training Program Requirements Update DQA Memo 08-026 announced approval revisions to Chapter DHS 129, Wis. Admin. Code. The purpose of this memo is to provide direction and guidance regarding the actual implementation of the changes that affected the training of feeding assistants as of 12/01/08. Feeding Assistant Training
Facilities for the Develop- mentally Disabled
Nursing Homes
09-007 Division of Quality Assurance (DQA) Memorandums Issued Prior to the Revised Wisconsin Administrative Code, Chapter DHS 83 Effective 04/01/09, the revised Chapter DHS 83, Wis. Admin. Code, DHS regulating community-based residential facilities, will be implemented. This Memo provides important information about previously issued DQA (former "BQA") Numbered Memos to CBRF providers. Community-based
Residential Facilities
09-008 09-008 - DHS 35, the New Outpatient Mental Health Clinic Rule - OBSOLETE 9/13 New standards for outpatient mental health clinics, ch. DHS 35, were adopted by DHS and sent to the Legislative Reference Bureau. The anticipated effective date of the rule is 06/01/09. To help prepare providers for changes in the regulations, presentations with Q&A sessions will be held in each of the regions. Rule information and training session schedule are included. Area Administrator /Assistant Administrators
Bureau Directors
County Departments of Human Services Directors
Tribal Chairpersons /Human Service Coordinators
Community Mental Health Providers
09-009 09-009 - Division of Quality Assurance Northeastern Regional Office Move - OBSOLETE 9/13 The purpose of this memo is to inform providers of the relocation of Bureau of Health Services (BHS), Bureau of Nursing Home Resident Care (BNHRC), Bureau of Assisted Living (BAL), and Bureau of Licensing, Technology, Education (BTLE) personnel currently housed at 200 North Jefferson St., Suite 211, Green Bay. Ambulatory Surgery Ctrs.
Adult Day Care Ctrs.
Adult Family Homes
Certified MH and AODA
Community-Based Residential Facilities
End Stage Renal Dialysis Units
Facilities for the Develop-mentally Disabled
Home Health Agencies
Nurse Aide Trng. Programs
Nursing Homes
Outpatient Rehab Facilities
Residential Care Apartment Complexes
Rural Health Clinics
09-010 Wisconsin Statutes, Section 157.06, Anatomical Gifts

Wisconsin Administrative Code, Section DHS 124.05(3)(i), Variance

2007 Wisconsin Act 106 was signed into law 03/17/08, codifying 2006 Revised Uniform Anatomical Gift Act (RUAGA) in the Wisconsin Statutes. This new law repealed and recreated section 157.06, Wis. Stats., effective 04/01/08.
The provisions of section DHS 124.05(3)(i), Wis. Admin. Code, relating to requirements for hospitals regarding anatomical gifts have now been superseded by section 157.06(14m), Wis. Stats.
09-011 Bureau of Assisted Living Restructuring to Four (4) Regions Effective 04/01/09, the Bureau of Assisted Living will cease operations in the Northern Regional Office in Rhinelander. Reassignments, maps, and telephone directory are included Adult Day Care Centers
Adult Family Homes
Community Based Residential Facilities
Residential Care Apartment Complexes

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HFS Administrative Rules Update

DHS 12 - Caregiver Background Checks

On September 15, 2008, the Wisconsin Administrative Rules website published the Initial Proposed Rulemaking Order including a summary and text of the proposed rule, Wisconsin Administrative Code, Chapter DHS 12. Section 50.065(2m)(d), Wis. Stats., requires the Department to promulgate rules to specify crimes for which an entity must disclose to a client or the client's guardian, a conviction of a caregiver who is assigned to provide personal care services to the client in the client's personal residence, and to specify who is a "substitute caregiver." The proposed rule was revised based upon comments received from advocacy organizations, trade and professional associations, and other interested parties.

On March 2, 2009, the Wisconsin Administrative Rules website published the Final Rulemaking Order including a summary and text of the proposed rule, Wisconsin Administrative Code Chapter DHS 12.

For more information, you may view the final rule order on the Wisconsin Administrative Rules website at:

DHS 83 - Community Based Residential Facilities

On April 1, 2009, revisions to Wisconsin Administrative Code, Chapter DHS 83 went into effect. The revised rule contains several changes that CBRF providers need to be aware of, including changes to the administrator qualifications, training requirements, medication administration requirements, and sprinkler system requirements for small class C facilities. The rule may be viewed at:

Staff from the Bureau of Assisted Living has developed industry training on the new requirements in DHS 83 for CBRF staff. The training is presented in four (4) modules and includes valuable handouts you can download that provide information on how the new rule will affect your facility. The training is web-based and available on the Wisconsin Department of Health Services website. You can access the training modules and handouts at:

Please watch for important memos related to the implementation of DHS 83. The link to the CBRF memos can be found at:

DHS 85 - Non-Profit Corporation as Guardian

On September 19, 2006, the Wisconsin Administrative Register published a Statement of Scope of proposed rules to amend Chapter DHS 85, Non-profit Corporation as Guardian. Through this initiative, the Department proposes to make the rule reflect current standards of practice, recognizing the increase in the number of adults in need of guardianship and the increase in the complexity of their needs.

An Advisory Committee, including advocates, providers, registers in probate, and County adult protective services staff, met and reviewed proposed rule language and made recommendations for change. The Department revised the proposed rule based upon comments from the Advisory Committee. The proposed Rule Order is currently under review by the DHS Office of Legal Counsel. For more information, you may view the Statement of Scope on the Wisconsin Administrative Rules website at:

DHS 124 - Hospitals

On April 1, 2005, the Wisconsin Administrative Register published a Statement of Scope of proposed rules to amend Chapter 124. The Department is planning to update Chapter DHS 124 to eliminate overly prescriptive and outdated regulations, clarify the Department's enforcement authority, and make the rule more consistent with the federal Medicare requirements.

The Department asked representatives from a large number of trade and professional associations, hospitals, and other interested parties, to review proposed revisions to the rule and make recommendations for change. The Department is reviewing their recommendations and preparing a revised draft of ch. DHS 124 for further review by stakeholders. For more information, you may view the Statement of Scope on the Wisconsin Administrative Rules website at:

DHS 129 - Certification Programs for Training and Testing Nurse Aides, Home Health Aides, and Hospice Aides

On December 1, 2008, revisions to Chapter DHS 129 went into effect. The revised rule includes training and testing requirements of feeding assistants and medications aides, reflects the standardization of the administration and operation of nurse aide competency evaluation by a contracted agency, improves the accuracy and integrity of the nurse aide registry, and expands the mechanisms available for enforcing compliance of training and testing programs. For more information, you may view the rule at:

DQA Memos 08-026 and 08-030 provide important information about the implementation of the revised rule and can be found at:

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CMS Survey & Certification Letters (January, February, March)

Listed below are Survey and Certification (S&C) Letters distributed by CMS during the last quarter. Please note that the CMS Internet site where you can review all S&C memos is: 

S & C No.



Providers Affected

09-18 The Five Star Nursing Home Rating System Questions and Answers The Five Star Nursing Home Rating System was launched on 12/18/08. The system offers a more user friendly way for consumers to compare nursing homes within a State. Memo provides a comprehensive set of Q&As. Nursing Homes
09-19 Advance Copy Hospice Program Interpretive Guidance Version 1.1 Memo includes advance copy of Hospice Interpre-tive Guidance, also to be published in an updated Appendix M of the State Operations Manual (SOM). Hospice
09-20 S and C Issues Related to Liability Notices and Beneficiary Appeal Rights in Nursing Homes Memo reviews a Skilled Nursing Facility provider's obligations to issue Medicare beneficiary liability notices; a Medicare beneficiary's rights related to standard claim and expedited appeals; and the surveyor's responsibility to determine compliance with Medicare notice and billing requirements for determinations of non-coverage. Nursing Homes
09-21 2009 Physician Fee Schedule Changes Affecting the Survey & Certification of Rehabilitation Programs On 11/19/08, CMS published revisions and updates to payment policies as well as conditions of participation (CoPs) under the Physician Fee Schedule. Rehab Programs
09-22 Revised Quality of Care Guidance at F309, including Pain Management as Part of Appendix PP SOM Revised guidance for long-term care surveyors at F309, Quality of Care, including new general investigative protocol and new pain management guidance and investigative protocol will be effective 03/31/09. LTC Surveyors
09-23 Entities with One CLIA Certificate for Multiple Sites Memo further defines and clarifies CMS existing policies for certification of laboratories performing limited public health testing. It also clarifies policies and procedures for the certification of entities with multiple sites, specifically home health agencies and hospices. CLIA Certified
Home Health Agencies
09-24 Implementation of the Life Safety Code Component for the New ESRD Conditions for Coverage Memo describes procedures CMS is implementing for the LSC provisions of the new ESRD Conditions for Coverage. While major portions of the ESRD regulation became effective on 10/14/08, the LSC component became effective on 02/09/09. End Stage Renal Disease
09-25 Enforcement of Amended Requirements for Certain Hospital and CAH Disclosures To Patients Revision to Physician-owned Hospital Disclosure Requirements. 42 CFR 489.3 and 489.20(u) and (v) were amended, effective 10/01/08. Hospitals
Critical Access Hospitals
09-26 Inpatient Prospective Payment System (IPPS) 2009 Final Rule Revisions to EMTALA Regulations Fiscal Year 2009 IPPS final rule included EMTALA revisions, effective 10/01/08. Regulatory pro-visions have been revised and reorganized. Technical corrections were made to track statutory language. Corresponding Interpreta-tive Guidelines in the State Operations Manual Appendix V are attached. Hospitals
09-27 Updated Interim Guidance Regarding the Temporary Mid-Level Staffing Waiver for RHCs Memo provides updated guidance regarding tem-porary mid-level staffing waiver for RHCs. This memo supersedes SC-09-14 issued 11/21/08. This update will reduce burdens on existing RHCs resulting from 1998 policy Rural Health Clinics
09-28 Publication of Proposed Regulations for Gynecologic Cytology Proficiency Testing (PT) under CLIA CMS announced publication of proposed regulations aimed at assuring competency of those conducting the Papanicolaou (Pap) test. The proposed rule would update current regulations implementing a statutory mandate that pathologists and cytotechnologists who screen Pap tests periodi-cally demonstrate their proficiency in examining and interpreting proficiency testing samples. CLIA Certified
09-29 FDA Warning to Nursing Homes Regarding Recalled Food Products Containing Peanuts The FDA is issuing a warning to nursing home and other long-term care facility administrators, owners, and food managers to ensure they are aware of the dangers of their residents eating recalled food products, and urging them to check their institutional supply of peanut butter and other products containing peanut ingredients for food items that may be affected by the recent voluntary recalls. Nursing Homes
Other Long-Term Care
09-30 Survey and Certification Issues Related to North Dakota and Minnesota Flooding Several States in the Midwest have been seriously impacted during this year's flooding season. The President has declared a national emergency in specified counties in North Dakota and Minnesota. The Acting Secretary of the U.S. Department of Health and Human Services has also declared a public health emergency in the North Dakota and Minnesota geographic areas covered by the President's declaration. CMS may waive or modify, to the extent necessary, certain requirements or timetables if providers, acting in good faith to provide needed forms and services, are unable to comply with the requirements as a result of the effects of the disaster. All


Content contact: Gina Bertolini
Phone: (608) 266-6691


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Last Updated: November 29, 2013